Chickenpox: What to Do, What Not to Put on It, and When It Is Not Mild

Call us before you bring a child with suspected chickenpox into the waiting room. That is not us being difficult — it is that a waiting room may contain a newborn, a pregnant person, or someone on chemotherapy, and chickenpox is airborne and extremely contagious. We will arrange how to see your child. Say “I think it might be chickenpox” when you call.

Then the reassuring part: in a healthy vaccinated or unvaccinated child, chickenpox is usually a miserable week rather than a dangerous illness. The work is comfort, hydration, and watching for the small number of things that change the picture.

What it looks like

It starts like a virus — fever, headache, tiredness, off food — for a day or two before any rash. The rash then appears in crops over three to five days, which is the tell:

• Flat red spots become raised bumps, then small fluid-filled blisters, then crust over
• Spots at different stages at the same time — some fresh, some blistered, some crusting. This is the feature that distinguishes it from most other rashes
• It often starts on the trunk, face or scalp and spreads outward
• It itches a great deal
• Spots can appear in the mouth, on the eyelids, and in the genital area, which is painful and worth knowing about in advance

A vaccinated child can still get it, more mildly — fewer spots, sometimes without blistering, sometimes without fever. That milder version is still contagious, and it is the one that gets mistaken for insect bites and sent to school.

Contagious for how long

From about two days before the rash until every spot has crusted over — usually about five to seven days after the rash starts.

That first bit is the reason it spreads so well: your child was infectious for two days while appearing entirely healthy. If your child has chickenpox, it is worth telling anyone they were with in that window, particularly if any of them is pregnant, has a new baby, or is immune-suppressed.

Schools and child care centres set their own return rules — usually once all spots have crusted. Ask them, and we can provide whatever note they need.

What helps

For the itch, which is the whole problem:

• Cool baths, with oatmeal or baking soda added. Pat dry rather than rubbing
• Calamine lotion on the spots
• An oral antihistamine can help, particularly at night. Ask us about which and what dose
• Keep fingernails short, and consider soft mittens for a baby or toddler. Scratching is what turns a spot into a scar or an infection
• Loose cotton clothing, and keep the room cool. Heat and sweat make the itch worse, which in a Phoenix summer means the air conditioning is doing medical work

For fever and discomfort: acetaminophen, dosed by weight. If you are unsure of a dose — the acetaminophen or the antihistamine — call and ask; out of hours a pharmacist can check a weight-based dose with you, and if you think a child has had too much of anything, Poison Control answers at any hour on 1-800-222-1222.

Two medicines to avoid, and this is the important part of the page

Never give aspirin to a child or teenager with chickenpox. The association with Reye syndrome — a rare but severe liver and brain condition — is strongest in exactly this illness.

Avoid ibuprofen and other NSAIDs during chickenpox unless we have specifically advised it. There is evidence linking NSAID use in chickenpox to more serious skin and soft-tissue infections. Acetaminophen is the one to reach for.

This is the single most useful thing on this page, because ibuprofen is what most families reach for by default for a feverish, uncomfortable child.

Fluids, in small amounts often. Mouth spots make eating and drinking genuinely painful — cold, soft, bland food, ice lollies, and avoid anything salty, acidic or crunchy.

Do not put a topical antibiotic or an over-the-counter anaesthetic cream on the spots unless told to. And no scratching aids that break skin.

Call us if

• You suspect chickenpox at all — call first, and see the top of this page
• A spot becomes hot, increasingly red, swollen, painful, or starts weeping pus, or a new fever appears after the first one settled. Spreading redness around a spot is a skin infection and it is the commonest complication
• Any difficulty breathing, a persistent cough, or chest pain
• A stiff neck, severe headache, repeated vomiting, confusion, unsteadiness, or a child who cannot be woken properly
• Spots in the eye, or eye pain and light sensitivity
• A child not drinking, or with no urine for eight hours
• Fever lasting more than four days, or a fever that goes and returns
• A child under three months, at all
• Chickenpox in a child with a weakened immune system, on steroids, or with eczema — all three change the management and need a prompt call
• Your child seems much more unwell than the rash explains

Go to an emergency room or call 911 for difficulty breathing, a seizure, a non-blanching rash of dark purple spots, or a child who cannot be roused.

The exposures that need a call the same day

Chickenpox is not dangerous to most children. It is genuinely dangerous to some people, and exposure — not illness — is the moment to act, because there are treatments that only work early.

Call us the same day if any of these has been exposed to chickenpox or shingles:

• A pregnant person who has not had chickenpox or the vaccine. This can seriously affect the baby, and the risk differs by stage of pregnancy
• A newborn, particularly if the mother develops chickenpox around the time of delivery
• Anyone with a weakened immune system, or on chemotherapy, high-dose steroids, or immune-suppressing medicine
• An adult who has never had it or been vaccinated. Chickenpox in adults is substantially more severe than in children, with a real risk of pneumonia

Prevention, and the shingles connection

The vaccine is why most parents reading this have never seen a case. Two doses, given in childhood, and it prevents most disease and nearly all of the severe kind. A vaccinated child who does catch it gets the mild version described above. Our immunizations page covers the schedule.

And the part worth knowing about yourself: the virus never leaves. After chickenpox it stays dormant in nerve tissue and can reactivate decades later as shingles — a painful, blistering rash in a band on one side of the body, sometimes with lasting nerve pain.

Two practical consequences:

Someone with shingles can give chickenpox to a person who has never had it, through contact with the blisters. Not shingles — chickenpox.

There is a shingles vaccine, recommended for adults from 50. If you are in that range and have never been asked about it, ask us. It is one of the more worthwhile adult vaccines and one of the most overlooked.

Sources

10. Chickenpox — MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine. https://medlineplus.gov/ency/article/001592.htm

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